This is the story of my nontraditional transformation from a Physics/Spanish/Chemistry/Math grad into a physician. I'm a proud member of the class of 2016 at Michigan State University's College of Human Medicine. The blog title will be edited to reflect the current stage of my transformation: Pre-Medical, Medical, Residential, then Doctoral. Read more about me in the My Story tab below. Enjoy!

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Thursday, October 3, 2013

Ethics Essay - "Killing" vs. "Letting Die"

In the second year here at MSU CHM, we take an ethics course for the first half of the first semester. This mostly involves reading ethics articles, writing ethics papers, and talking everything over. I don't know whether or not most med schools do this kind of thing, but I'm willing to bet that the places which have an Ethics class aren't quite as in depth with it as CHM. We're split into small groups of 6-8 students per group, and each group has a preceptor, usually a clinician. We meet only once per week for two hours. The class only lasts eight weeks. During those eight weeks, we have to write at least five of the eight possible "Weekly Essays." The topics are prescribed, and the grades for these essays comprise the bulk of the course grade. My understanding is that the course isn't really designed to be difficult to pass, but it's more designed to make you think about things from different perspectives, gaining an understanding of what clinical ethics is along the way.

This week, the essay took its springing point from one of our online lectures, which outlined an argument for claiming that there is an important difference between "killing" and "letting die":

“Killing is an action, where directly causing the death is the goal of the action. Letting die is a failure to
act, where the resulting death is not the primary goal.” Construct an argument that shows either that 1) this is not a defining difference between “killing” and
“letting die”; or 2) that it is not an ethically important difference; or both. (Critical reasoning)I gave it a whirl, and it wasn't the easiest paper to write, since for the most part I agree with the prompting statement. A lot of old-school physicians would probably agree wholeheartedly with the idea that there's no difference between killing someone and letting them die. This was actually the opinion of a doctor we saw in a video from the 70s who refused for more than a year to allow a total-body-burn victim to refuse treatment and die. That doctor very clearly said that by allowing his patient to refuse treatment and die rather than doing the procedures of which he was capable, he would effectively be murdering his patient. He never considered the concept, as explained by the interview with his patient in the same video, that there are worse things to experience than death. There's a big difference in culture between medicine today and medicine 40 years ago. Back then, doctors more regularly had greater power to do everything they could to save a patient than we do today. Patient autonomy is much more highly valued in today's medical culture than it was a while ago. SO, I tried to write my article as though it were from the viewpoint of that old-school physician. Regardless, I constantly felt like my essay was full of holes even as I was writing it - holes that, if I were actually arguing against what I was writing, I would gladly exploit. I think this was the point of the experience, since given that most doctors have to "let die" all the time, most doctors would probably agree that there is an ethically important difference between that and "killing." Anyway, here is the essay I ended up turning in. I'm really not looking for comments on this post - this is more for my recollection years from now about what kinds of things we did in Ethics class. :)

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To discuss whether or not there is an ethically important
difference between “killing” and “letting die” based on the proposed concepts
that “Killing is an action, where directly causing death is the goal of the
action. Letting die is a failure to act, where the resulting death is not the
primary goal,” we must first define two concepts. First, the concept of an
“action,” and second, the concept of what defines an “ethically important
difference.”

I propose
that an individual’s “action” is any operational course taken by that
individual with the expressed or unexpressed intent to bring about any single
or multiple consequences. Of utmost importance is the concept that a choice by an individual to subscribe to a
course of inaction alsoconstitutes a course of action.

I also propose that we define an
“ethically important difference” as one that is in line with Lo’s definition of
clinical ethics. Lo states that “[w]e use the term ethics to refer to judgments
about what is right or wrong and worthy of praise or blame.” (Lo, Ch. 1). The
context of this statement by Lo is one of judgment about what is right or wrong
in a moral setting – not one of clinical correctness. As such, an “ethically
important difference” must be one that differentiates between operational
courses in a manner that allows their categorization by intention as either
morally right or morally wrong.

In applying
the above rationale regarding ethically important differences to a proposed operational
course, the morality of intention of that operational course must be carefully
considered. The morality of the operational course is determined by the goals
motivating the selection and implementation of that course, and whether those
goals are right or wrong. Here is where a key factor enters into the equation. The goals motivating a rational and
capacitated individual’s selection and implementation of a particular course of
action will include both the direct and indirect effects of that action. As
rational beings capable of gauging cause-and-effect, intellectually capacitated
human beings are capable of assessing the intended primary and a reasonable
number of the subsequent “ripple” effects of their actions. That is, with
careful consideration, most humans are able to recognize the direct and most
indirect outcomes of their actions.

In the
context of this argument, I argue that (as rational, intellectually capacitated
human beings) physicians are capable of conceptualizing both the direct and
indirect effects of a given potential course of action. Thus, both the direct
and indirect effects of a potential course of action must be factored into that
which constitutes the physician’s goals, or intentions, as he or she selects
among various proposed operational courses. Additionally, any action that is
intended to cause the direct or indirect death of another individual must be
termed immoral. By Lo’s definition of clinical ethics, any action in this way
deemed immoral must be of ethical significance.

Having
established these definitions and logical relationships, I return to the
discussion at hand. I have shown that choosing a course of inaction in essence
constitutes choosing a specific course of action. I have also made the case
that, for a rational and intellectually capacitated individual, the motivation
behind any course of action must include the intended outcomes, both direct and
indirect, of that course of action. Just because a foreseeable outcome of an
action is indirect in nature does not exclude that action from possible moral
and ethical consideration. Thus, if the death of another individual is an
intended, indirect result of action, then that action is considered immoral and,
by Lo’s definition, of ethical significance.

There is no “ethically important
difference” between “killing” and “letting die” in the context of the
statements that “Killing is an action, where directly causing death is the goal
of the action. Letting die is a failure to act, where the resulting death is
not the primary goal.” By choosing to act via inaction in a way that
intentionally results in death effectively equates “letting die” to “killing.”
In such a context, the only difference between these two terms is one of
spelling and semantics. Ethically, there is no difference between them. They
are both courses of operation that intentionally result in death.